Form Dl-79 - Removal Request Form - Medical Review Program - North Carolina Division Of Motor Vehicles


North Carolina Division of Motor Vehicles
Medical Review Program
Removal Request Form
Name (First, Middle, Last):
Date of Birth:
North Carolina Driver License Number:
Reason for
Important: Submitting a removal request does not indicate or guarantee removal from the
Medical Review Program. Your records will be reviewed to determine if you may be removed.
You will receive a letter by mail once your request has been received.
You may need to submit additional or updated medical information in order for your request to
be processed. If additional information is required, you will be notified by mail.
Once a final decision is made, you will receive a letter by mail.
Submitting a removal request does not delay or reverse any license restrictions. If you received
a letter that restrictions must be placed on your license, please visit your local Driver License
Agency to have the restriction(s) placed.
Please mail or fax all removal requests to:
Medical Review Program, 3112 Mail Service Center, Raleigh, NC 27697-3112
or fax to (919) 733-9569, Attention: Medical Review Program
Rev. 12/16


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